Nokea
The nurse teaches the client to monitor which newborn condition?
- A. Umbilical cord stump for infection
- B. Daily weight gain over 1 pound
- C. Frequent crying as abnormal
- D. No bowel movements for a week
Correct Answer: A
Rationale: Monitoring the umbilical cord stump for infection (redness, discharge) is critical for newborn health.
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The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?
- A. “Usually making an episiotomy incision is avoided whenever possible.”
- B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
- C. “An episiotomy is routine because it can prevent pelvic floor damage.”
- D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A
Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
- A. Eat crackers while still in bed in the morning.
- B. Lie down and rest whenever nausea occurs.
- C. Eat more frequently throughout the day.
- D. Avoid food items containing ginger.
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.
Which statement by the client indicates understanding of prenatal education?
- A. I should avoid all exercise during pregnancy.
- B. I need to attend prenatal visits only in the third trimester.
- C. I should report any decrease in fetal movement.
- D. I can consume alcohol in moderation after the first trimester.
Correct Answer: C
Rationale: Reporting decreased fetal movement is critical, as it may indicate fetal distress, showing the client understands key prenatal education.
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.